Listen, hear, act: challenging medicine's culture of bad behaviour

There is no place for humiliation, discrimination or any kind of harassment in medical education

A perfect storm occurs when a situation is exacerbated by a rare combination of events. In recent media reports, there has been a perfect storm of accusations of every kind of abuse levelled against the medical profession by some of its own. Abuse is not new. Few who have experienced medical training can honestly say we have never seen nor been victims of any form of bullying or humiliation throughout that process. But the rare exacerbation early this year was the separate deaths of four junior trainees, apparently by suicide, followed soon after by Dr Gabrielle McMullin's comments about the sexual harassment of female surgical trainees.1

The tragic deaths of the young doctors triggered my recent article in Croakey;2 but before that there was a long-brewing frustration fuelled by endless stories from students and doctors — of sexual harassment, bullying, teaching by humiliation, discrimination and the trauma of medical education — and by my own experiences of being a woman in medicine.

One reader's comment in Croakey was particularly confronting.

Looking back over nearly four decades since I entered medical school, I know my reader is right: much is said, but little changes. Well intentioned programs, policies and services are in place, but, as the reader continued,

The services, supports and reporting pathways are there, so why don't doctors use them? Perhaps the strongest example of why not was revealed by McMullin's suggestion that female surgical trainees who are asked for sexual favours by senior colleagues should oblige rather than risk their careers. The ensuing uproar suggests McMullin is an astute media tactician. Despite the vocal insistence of medical organisations to the contrary, McMullin stood firm that current systems are not solving the problem.

This is not a problem only for women or surgeons. My inbox was flooded with stories from women and men experiencing harm at the hands of colleagues and the system. One male intern wrote:

A male senior student wrote,

The Royal Australasian College of Surgeons,4 the Australian Medical Association5 and the Victorian Health Minister6 have now all weighed in with a range of proposed reviews and taskforces. Frank and fearless examination of current processes is welcome, but it must genuinely aim to remove the significant barriers to doctors using them without personal peril. Negative impacts on the right to practise and on career progress are among the most common reasons doctors cite for not seeking treatment or support for mental health conditions.7

What needs to change most is a medical culture that condones and even encourages bad behaviour. That will not happen through advisory panels and external forces. Medicine is a complex, multicultural affair: a loose coalition of high-achieving, competitive individuals belonging to numerous workplaces and associations, each with its own internal hierarchies and cultures. No single person in medicine has the power that the former Chief of Army, Lieutenant General David Morrison, displayed in his unequivocal response to sexual harassment in the army.8 Also unlike soldiers, doctors are trained to work autonomously: to give, rather than take, orders.

For most of the past two centuries, doctors stood atop the health care pyramid and enjoyed enormous autonomy and deference. But as society began to change after World War II, so too did medicine.

More women entered medicine, and gender parity among students occurred around the mid 1970s. And yet, that gender balance is still not reflected in most specialist training schemes or in the medical workforce where the ratio of women to men is 2 : 5.9 More worryingly, selection criteria seem once more to be favouring male students.10

Consumers began to demand more say in their care and increasingly held doctors to account; legislation and external regulatory bodies became more prominent in governing doctors' actions; non-medics took over hospitals; and interdisciplinary teams became the new work paradigm. However, the training and expectations of doctors to be on top of the pyramid remain largely unchanged. I wonder if some of the bad behaviour we see is symptomatic of a profession struggling to adapt to lost status. Cultural change is difficult, and resistance is common.

Whatever the cause of medicine's discontent, for change to start, we must first accept that we have allowed a workplace culture in which incivility and frank bullying are commonplace. There are too many deniers and too much victim shaming in the current commentary. “It didn't happen to me, therefore it didn't happen”, is not evidence. Simply suggesting junior doctors develop “resilience strategies” and “stand up to bullies” is further victim blaming.11

Bad behaviour is often unconscious. Like evil, it is banal and takes hold when the unthinkable becomes normalised as the way things are and people fail, for fear or favour, to challenge the status quo.12 The belief that, to succeed, it is necessary to acculturate to, accommodate and perpetrate this negative culture is, sadly, all too common. It's time to stop talking and harness one of medicine's most powerful and underused diagnostic skills: listening. All the taskforces and policies in the world will not make an iota of difference if the victims' voices are silenced by fear or shame.

Change is most successful if it's modelled from the top. As medicine has no single chain of command, leaders committed to genuine change must be championed and supported to implement a zero-tolerance approach. Training in respectful communication could be made mandatory for all teachers and supervisors. Feedback and appraisal mechanisms can be built into performance reviews and accreditation processes. Providing an independent regulatory authority such as a health workplace ombudsman13 deserves serious consideration as a safe pathway for raising concerns and getting support, and for removing those in power who refuse to change.

It is possible to learn skills to improve your ability to communicate and to model positive behaviour. At the University of Sydney, for example, we are developing workshops to train health professionals in acting skills. Actors are able to be fully engaged within a role while also observing their own performance and adapting it to the situation. By practising these skills, doctors can start to recognise the impact of their actions on others and to safely challenge the normalisation and perpetuation of bad behaviour.

But real change also requires each of us to listen to our conscience and ask, “Am I part of the problem?”. It requires individuals to challenge “the way things are” so that reporting bad behaviour becomes everyone's responsibility, not just the victims'. The consequences of bullying and harassment are reduced concentration, anxiety, compromised communication and poor team work. Shooting the messenger does great harm. It is killing both doctors and patients. What we cannot allow to happen is for the prediction of my reader to come true: